Concordia at Spiritrust Luther Ridge

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of one resident reviewed for catheters (Resident 8).

Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one residents reviewed receiving dialysis (Resident 41).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for three of five residents reviewed (Residents 4, 7, and 8). Findings Include: Facility policy, titled Drug Regimen Review, last reviewed January 2026, read, in part, PROCEDURE: 1. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physician and the care planning team. 2. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review (approximately 30 days) .3. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 12 residents reviewed (Residents 4 and 7).

Inspectors wroteBased on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in actual harm as evidenced by a fall with facial injury, which required sutures for one of three residents reviewed for falls (Resident 1).

Inspectors wroteBased on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the practitioner was notified of missed medication administration when medications were unavailable for four of 13 residents reviewed (Residents 12, 14, 15, and 19) and failed to provide treatment in accordance with professional standards of practice and physician orders for one of 13 residents reviewed (Resident 25).

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for four of 17 residents reviewed (Residents 12, 14, 15, and 19). Findings Include: Review of facility policy, Medication Administration, last revised June 2023, revealed, Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. [...]

Inspectors wroteBased on facility policy review, clinical record review, review of facility documents, and resident and staff interviews, it was determined that the facility failed to report an allegation of abuse and/or neglect to the required agencies in a timely manner for two of two residents reviewed (Residents 6 and 17).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 14 residents reviewed (Residents 6 and 8).

Inspectors wroteBased on facility policy review, clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of two residents reviewed for falls (Resident 6).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for two of five residents reviewed for unnecessary medications (Residents 6 and 27).

Inspectors wroteBased on surveyor observations, facility policy, and staff interviews, it was determined that the failed to place opened dates on medications in one of two medication rooms (Arlington Unit) observed. Findings Include: Review of facility policy, titled Multi-Dose Medication Storage, with a revision date of May 21, 2025, read, in part, Facility will date multi-dose vials when opened, for the purpose of infection control and to ensure product stability. Observation of the medication storage room refrigerator on May 29, 2025 at 11:00 AM, with Employee 1, revealed two open multi dose vials of Tuberculin solution (a sterile solution, primarily Purified Protein Derivative (PPD), used for diagnosing tuberculosis) with no open dates. During a staff interview with Employee 1 on May 29, 2025, at 11:00 AM, it was revealed that multidose vials should be dated when opened. [...]

Inspectors wroteBased on review of the sign-in sheets for the facility's Quality Assurance Performance Improvement (QAPI) Committee and staff interview, it was determined that all the required members failed to attend at least one meeting in one out of three quarterly meetings.

Inspectors wroteBased on review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for two of five nurse aide employee records reviewed (Employees 2 and 3).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon in a timely manner for four of five residents reviewed for unnecessary medications (Residents 2, 13, 17, and 29).

Inspectors wroteBased on policy review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported immediately for one of one resident abuse reports reviewed (Resident 38).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 15 residents reviewed (Resident 18). Findings Include: Review of Resident 18's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and localized edema (swelling caused by excess fluid accumulation in the body tissues). Review of Resident 18's June and July 2024 TARs (Treatment Administration Records - forms used to document physician orders as well as when and how treatments are administered to a resident) revealed an order for daily weights; [...]

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional standards of practice for one of one resident reviewed (Resident 32) receiving dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidney can no longer perform these functions naturally). Findings Include: A review of the facility policy, titled Hemodialysis Resident Care Standard, last reviewed July 19, 2024, stated that the facility will assure safe medical management of residents who receive dialysis in a dialysis clinic, outside of the facility. [...]

Inspectors wroteBased on observation, staff interviews, policy review, and clinical record review, it was determined that the facility failed to document completely and accurately on the clinical records for one of 15 residents reviewed (Resident 86).

Inspectors wroteBased on facility policy review, observations, and staff interview, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents reviewed for transmission based precautions (Resident 14) and one of one residents reviewed for pressure ulcers (Resident 14).